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Home My WebLink AboutBLDP&G-24-371 MASSACHUSETTS UNIFORM APPLICATION FOR PER IT TO PERFORM PLUMBING WORK CITY _ r 11 MA DATE PE MIT#/3LL)P" V 3/7/ JOB SITE ADDRESS WNER' NAME ft re 4514 S/O(f p OWNERADDRESSZ.C7 4A/rY*0 rtte r IzrA i)7 FAX TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL❑ RESIDENTIAL PRINT CLEARLY NEW:0 RENOVATION:❑ REPLACEMENT:il PLANS SUBMITTED:YES 0 NO'I FIXTURES? FLOOR-, 13SM 1 2 3 4 5 6 7 6 9 10 11 12 13 14 BATHTUB _ _ _ CROSS CONNECTION DEVICE _ DEDICATED SPECIAL WASTE SYSTEM _ DEDICATED GASIOIUSAND SYSTEM _ DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM _ _ _ DEDICATED WATER RECYCLE SYSTEM _ _ DISHWASHER DRINKING FOUNTAIN _ FOOD DISPOSER _ _ FLOOR I AREA DRAIN _ _ INTERCEPTOR(INTERIOR) KITCHEN SINK LAVATORY s ROOF DRAIN k ' -- SHOWER STALL SERVICE 1 MOP SINK _ g ]�j _ TOILET URINAL BU a,rtIIG''r PAID _ j WASHING MACHINE CONNECTION -_-- WATER HEATER ALL TYPES / _ ,w __ WATER PIPING _ OTHER INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES ] NO❑ IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POUCY i] OTHER TYPE OF INDEMNITY 0 BOND 0 OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the 1 Massachusetts General Laws,and that my signature on this permit application waives this requirement. 2 CHECK ONE ONLY: OWNER 0 AGENT 0 SIGNATURE OF OWNER OR AGENT 141 I hereby certify that all of the details and Information I have submitted or entered regarding this application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all Pertinent provision of the Massachusetts State Plumbin Code and C hapter 142 of the General Laws. C� PLUMBER'S NAME �)ClAcIL°L V pvt e_ LICENSEE# /O/. SIGNATURE MP 0 JP C�ORPPOORATION❑#NCO PARTNERSHIP / LLC 0# COMPANY AMEN C&`I t) P" w ADDRESS `3 r n�'r �7l q� CITY G 1 n 6 5 STATE 6 ZIP d &e/ TEL 7 j7`/q/6 [I?2_ FAX CELL EMAIL 5"1 1�1Qf,"'l�8`-i b12®5 MA')L`CAM ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# PLAN REVIEW NOTES • � MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY r- • MA DATE 'x I � a / h'!�l ��Zl�Z/ PERMIT �� y JOBSITE ADDRESS 32- /?4/ /j()440 OWNER'S NAME ct s i d Li GOWNER ADDRESS?j-( 7/1 6 r-(4 n I! 61 DEL 7 5 — ci FAX TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL( .. PRINT CLEARLY NEW:❑ RENOVATION: ❑ REPLACEMENT: PLANS SUBMITTED: YES❑ NO Cla'. APPLIANCES 1 FLOORS-F BSM 1 2 3 4 5 6 7 ° 9 10 11 12 13 14 BOILER BOOSTER CONVERSION BURIVEP, COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE 1 FRYOLATOR FURNACE GENERATOR GRILLE F — INFRARED HEATER LABORATORY COCKS • MAKEUP AIR UNIT OVEN • POOL HEATER • ROOM I SPACE HEATER T ROOF TOP UNIT .R C E I V : D TEST ___ UNIT HEATER UNVENTED ROOM HEATER APR 1 a 2024 WATER HEATER / i OTHER �i " �'r __ _—_ __ BUILDING E EPARTMENT _----. I INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES gl NO ❑ I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY] OTHER TYPE INDEMNITY ❑ BOND ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws,and that my signature on this permit application waives this requirement. ., CHECK ONE ONLY: OWNER ❑ AGENT ❑ SIGNATURE OF OWNER OR AGENT t I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the best of my knowledge \'- and that all plumbing work and installationsperformed under the permit issued for this p / � lication will be in compliance all eminent provision of the �� Massachusetts State Plumbing Code and Chapter 142 of the �General Laws. r /ff PLUMBER-GASFITTER NAME MCYYj Q Qr �` LICENSE# SIGNATURE MP ❑ MGF❑ JP, JGF❑ LPGI ••CORPORATION❑# P rQ P PARTNERSHIP❑t LLC El# COMPANY NAME r �j �G� GBQ C L94. ADDRESS 3 y f' �)�l t (/'e �ICITY l 1q �1 /1 t S / STATE J ZIP D z / a / TEL 7 7/ r/?ia CO 1� D FAX CELL EMAIL - jROUGB GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# PLAN REVIEW NOTES